What is the normal preoperative workup for a patient with a fracture?

Normal Preoperative Workup for Fracture Patients

Full blood count and urea and electrolyte analyses are required routinely before fracture surgery, while coagulation studies and chest radiography should only be performed if clinically indicated. 1

Essential Preoperative Investigations

Laboratory Tests

• Full Blood Count (FBC):

  • Critical for identifying pre-operative anemia (occurs in ~40% of patients) 1
  • Pre-operative transfusion should be considered if:
    • Hemoglobin < 9 g/dl
    • Hemoglobin < 10 g/dl with history of ischemic heart disease 1
  • Blood crossmatching requirements:
    • Hb 10-12 g/dl: crossmatch two units
    • Normal Hb: grouped sample sufficient
    • Revision surgery/periprosthetic fractures: follow local crossmatching guidelines 1
  • Leukocytosis > 17 × 10^9/l may indicate infection (chest or urinary) 1
  • Platelet count < 50 × 10^9/l requires pre-operative platelet transfusion 1

• Urea and Electrolytes:

  • Essential for all fracture patients 1
  • Identifies:
    • Hypokalaemia (risk for new-onset atrial fibrillation)
    • Hyperkalaemia (may indicate rhabdomyolysis in immobilized patients)
    • Hyponatraemia (common in 17%, may indicate infection or medication effect) 1

Cardiac Assessment

• Electrocardiogram (ECG):
  • Required for all elderly patients with fractures 1
  • Essential for identifying pre-existing cardiac conditions

Imaging

• Fracture Radiography:
  • Plain radiography with appropriate views to confirm diagnosis 2
  • For suspected occult hip fractures with normal radiographs, MRI should be ordered 2
• Chest X-ray:
  • Not routinely necessary unless clinically indicated 1
  • Indicated for patients with newly diagnosed heart failure or pneumonia 1

Special Considerations

Anticoagulation Management

• Aspirin:
  • May be withheld during inpatient stay unless specifically indicated 1
• Clopidogrel:
  • Generally not stopped on admission, especially with drug-eluting coronary stents
  • Surgery should not be delayed, but expect marginally greater blood loss 1
• Warfarin:
  • INR should be < 2 for surgery and < 1.5 for neuraxial anesthesia 1

Medical Condition Assessment

• Co-morbidities:
  • Assess cardiovascular disease (35%), respiratory disease (14%), cerebrovascular disease (13%), diabetes (9%), malignancy (8%), and renal disease (3%) 1
  • Evaluate musculoskeletal abnormalities, skin condition, pressure areas, dentition, and hearing aids 1

Medication Review

• Polypharmacy:
  • Review current medication list for inappropriate dosing and potential interactions 1
  • 20% of people over 70 take more than five medications 1

Timing of Surgery

• Surgery should be performed within 48 hours of injury to reduce morbidity and mortality 1
• Rapid optimization of fitness for surgery improves outcomes 1

Common Pitfalls to Avoid

1. Overlooking anemia: Pre-operative anemia can lead to significant post-operative anemia, risking myocardial and cerebral ischemia 1

2. Misinterpreting leukocytosis: Leucocytosis and neutrophilia are common (45% and 60% respectively) and may be reactive responses to trauma rather than infection 1

3. Unnecessary testing: Routine preoperative screening tests have limited value in ambulatory surgical patients and should be ordered selectively based on clinical indications 3

4. Ignoring abnormal platelet values and bilirubin levels: These have been shown to predict post-operative cardiac arrest and septic shock respectively in trauma patients 4

5. Delaying surgery: Delay beyond 48 hours increases mortality and complications due to immobility 1

By following this structured approach to preoperative workup, clinicians can effectively prepare fracture patients for surgery while minimizing unnecessary testing and avoiding preventable complications.